FlyteHealth

Health Information Exchange Patient Form

A Health Information Exchange ("HIE") is a safe way for healthcare providers to get the most up-to-date health information. The HIE will allow FlyteHealth to access or share your health information with other healthcare providers (internally at FlyteHealth and externally with other clinical providers who are overseeing your health care conditions). This may improve your overall clinical care through the use of an electronic medical record that either FlyteHealth manages, or other third party systems that your additional clinical care providers submit information to or manage themselves. By signing this form, you are agreeing that your personal health information, including test results, lab reports, X-rays/imaging studies, medication lists, or any other relevant personal health information, may be shared across participating healthcare organizations and clinical providers, including FlyteHealth.

You acknowledge that you have read this form, were given the opportunity to ask questions, and received answers that you understood.

1. I understand that I may revoke this authorization at any time by submitting a written request to my clinical provider and FlyteHealth. I understand that if I withdraw authorization, no new health information may be shared with the other clinical providers and their supporting staffs, including FlyteHealth, and may not be used unless it has already been used in reliance on my previous authorization. This authorization will be shortened, extended, or will cease to be effective on the date the written instructions are received except to the extent action it has already been taken in reliance upon it.

2. I understand that personal health information used or disclosed pursuant to this HIE authorization may be subject to re-disclosure by the recipient outside of FlyteHealth and no longer be protected by state or federal privacy regulations. However, other state or federal laws may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

3. I understand that my refusal to sign this HIE authorization will not jeopardize my right to medical treatment from FlyteHealth or payment for my medical treatment except where disclosure of my health information is required for the provision of medical treatment or to obtain payment for medical treatment.

Use of Personal Health Information

These are the following details related to the electronic personal health information exchanged (accessed or shared) through AthenaOne (the electronic medical records platform used by FlyteHealth and integrated with the FlyteHealth patient application); CommonWell, a not-for-profit trade association devoted to the simple vision that health data should be available to individuals and caregivers regardless of where care occurs https://www.commonwellalliance.org/about ; and Care Quality, the interoperability framework that is connecting health information networks throughout the United States of America ( https://carequality.org ) and your HIE consent process:

1. How Your Information May be Used. Your electronic personal health information will be used by the organizations, clinical providers, or programs set forth above only to:

  • Provide you with medical treatment and related services.
  • Check whether you have health insurance and what it covers.
  • Conduct care management activities to assist you in obtaining appropriate medical care, improving the quality of medical treatment services provided to you, coordinating the provision of multiple healthcare services provided to you, or supporting you in following a plan of medical treatment and clinical care.
  • Evaluate and improve the quality of medical care provided to all patients.
  • Limited to AthenaOne: Support research directly related to the COVID-19 Public Health Emergency, as permitted by law through the duration of the public health emergency.

Unless otherwise permitted by state and federal law, your electronic personal health information shall be disclosed, accessed, and used by healthcare insurance plans (commercial, Medicare, and self insured employers) who are affiliated with FlyteHealth only to:

  • Provide Care Management Activities. These include assisting you in obtaining appropriate medical treatment and clinical care, improving the quality of healthcare services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical treatment and clinical care.
  • Provide Quality Improvement Activities. These include evaluating and improving the quality of medical treatment and clinical care provided to you and all FlyteHealth patients and members.

NOTE: The choice you make in this HIE Consent Form does NOT allow health insurance companies or your employer to have access to your individual information for the purpose of deciding whether or not to provide you with health insurance coverage or pay your medical bills.

2. What Types of Information About You Are Included. When you give your HIE consent, the health information exchange services and electronic medical record platforms listed above may access ALL of your electronic personal health information available in your FlyteHealth electronic medical records. This includes all participating organizations and all employees, agents, and members of the medical staff of FlyteHealth and affiliated entities with FlyteHealth. This includes personal health information created before and after the date of this HIE Consent Form. Your personal health records may include a history of illnesses or injuries you have had (e.g., diabetes or a broken bone), test results (e.g., X-rays or blood tests), and lists of medicines you have taken.

This information may relate to sensitive health conditions, including but not limited to:

  • Alcohol or drug use problems
  • Allergies
  • Birth control and abortion (family planning)
  • Claims Encounter Data
  • Clinical notes
  • Diagnostic Information
  • Discharge summary
  • Employment Information
  • Genetic (inherited) diseases or tests
  • HIV/AIDS
  • Lab Test
  • Living Situation
  • Medication and Dosages
  • Mental health conditions
  • Sexually transmitted diseases
  • Social Supports
  • Substance use history summaries

3. Effective Period. This HIE Consent Form will remain in effect until the day you change your consent choice, death, or until such time as the applicable HIE ceases operation. If consent is signed by a parent or legal guardian of a minor, the consent decision will expire on the 18th birthday when the minor becomes an adult, and the patient will have to file a new consent decision. If any FlyteHealth affiliated health information exchange merges with another health information exchange, your consent choices will remain effective with the newly merged entities.

4. Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance ("Information Sources"). These may include hospitals, physicians, nurse practitioners, nurses, medical assistants, registered dietitians, pharmacies, clinical laboratories, health insurers, Medicare (if applicable), Medicaid (if applicable), and other health organizations that exchange personal health information electronically.

5. Who May Access Information About You, If You Give Consent. Physicians, nurse practitioners, nurses, medical assistants, registered dietitians, pharmacies, clinical laboratories, health insurers, Medicare (if applicable), Medicaid (if applicable), employees, trainees, students, volunteers, and agents other health organizations that you have given consent to access your personal health information electronically in order to carry out activities permitted in this HIE Consent Form as described above.

6. Public Health and Organ Procurement Organization Access. Federal, state, or local public health agencies and certain organ procurement organizations are authorized by law to access personal health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information for these purposes without regard to whether you give consent, deny consent, or do not fill out a consent form.

7. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic personal health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, you can contact the FlyteHealth Privacy Officer by calling 844-359-8363. If at any time you suspect that someone should not have seen or gotten access to information about you, you can contact us compliance@flytemedical.com.

8. Re-disclosure of Information. Any organization(s) you have given consent to access personal health information about you in the HIE Consent Form may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

9. Changing Your Consent Choice. You can change your consent at any time by signing a new HIE Consent Form with your new choice. You can obtain the HIE Consent Form from by contacting FlyteHealth at mymedicalrecords@flytehealth.com for us to update your HIE Consent designations.

10. Copy of Your HIE Consent Form. You are entitled to get a copy of this HIE Consent Form at any time by sending an email mymedicalrecords@flytehealth.com.

Note: Organizations, including any clinical providers that participate in the health information exchanges noted above, that access your personal health information as noted in this HIE Consent Form, while your consent is in effect, may save, copy, or include your personal health information in their own medical records. Even if you later decide to withdraw your HIE consent with FlyteHealth, the affiliated health information exchange platforms and clinical providers who access them are not required to return your personal health information to you or remove it from their records.

I understand that I can request a copy of this HIE Consent Form after I sign it. A photocopy of this form will be considered as valid as the original. I hereby acknowledge that I have received my clinical provider’s Healthcare Information Exchange Patient Authorization. I agree to the terms of this authorization. This HIE Consent Form applies and extends to subsequent telehealth visits and appointments with all FlyteHealth affiliated clinical providers.

You have the following choices:

By clicking ACCEPT you agree that I GIVE CONSENT to ALL of the organizations, clinical providers, and programs explained in this HIE Consent Form to access ALL of my electronic personal health information. And, I GIVE CONSENT to ALL employees, agents and members of the medical staffs of FlyteHealth and affiliated entities to access ALL of my electronic personal health information through all of the organizations, clinical providers, and programs explained in this HIE Consent Form, including AthenaOne, CommonWell, and Care Quality, in connection with any of the permitted purposes described in the fact sheet, including providing me any healthcare services and medical treatment.

By clicking DECLINE you agree that I DENY CONSENT to the organizations, providers, and programs explained in this Authorization Form that would otherwise require my consent to access my electronic personal health information in my FlyteHealth medical record, and I DENY CONSENT to employees, agents and members of the medical staff of FlyteHealth and affiliated entities to access my electronic personal health information for any purpose, even in a medical emergency.